Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

Thursday, October 09, 2008

Physicians suspected when EMTALA was passed that it was a set-up for a government takeover of health care in America.

The sub-prime meltdown is EMTALA writ large on our economy and the answer, after the government forced banks to provide mortgages to people that would not otherwise have qualified (here for example or simply click below) is, genius move, to get the government more involved.

Since Obama has declared health care a 'right' let me explain to those of you outside of health care what will follow if it is given a firmer foundation than it already has in EMTALA.

1. Care will be rationed. It's just that simple, all the other consequences are obvious, but this is the most important one for you.2. Physicians will quit, retire early, cut their hours, or otherwise opt out.3. The rich will still get excellent care either legally or illegally, but it will be unavailable for ordinary folks (see #1).

With a 'right' comes a 'responsibility'. If health care is a 'right' then who is responsible for it?

For the last twenty five years the answer has been the taxpayer, physicians, hospitals, and insurance companies (and the system has nearly broken under it's weight). When the 'right to health care' is enshrined along with 'life, liberty, and the pursuit of happiness'then, and this is not a bad thing at all for doctors (in theory, all the care we deliver will be compensated but at rates set by the government), 'the rich' will pay for it, and, 'the rich' will be defined by your government. The magic number for being rich, depending on who you listen to, is either an aggregate income of $250,000, or, according to the conservative media, folks making more than $45,000 a year.

I will make more money, initially, with an Obama-like plan, and I will not work as hard. It is idiocy. For many of you who are fairly healthy it will be great. When you get really sick, however, you will wait. Depending on where you live you may wait till after you die because there will be no incentive for hospitals or physicians to see more patients or to expedite treatment. In fact, if tort reform is not enacted with Obama-care, it will be a really bad idea to see more patients than your banker's hours allow, and a disincentive to take on difficult cases.

Welcome to the world stood on it's head. See you in line for free food. Farmers and grocers, you're next.

97 comments:

Founding fathera are weeping. I never signed on for communism. How do I get off the bus? Rural Missouri is ok. Have not been assimilated yet. Nor eaten by natives. Sorry if cryptic. Only blackberry available for net.

Absolutely right. Well put - it's utterly frightening how many people blindly rally for universal health care, unaware of the downsides. Long may you remain hard right smartasses - and count me among your ranks.

What McCain and Palin need to you is to attack this on a philosophical level. I like to confront liberals, as frequently as I can, with the moral ramifications of their rhetoric. I present it like this:

" I want you to be morally honest. If you feel that stealing and looting from others is justified to give you what you regard as your "needs" I want you say it. If you feel that people should be forced to live at your expense, I want you to say it. If you feel that society's thinkers, inventors, creators, healers, should be dragged to your sacrificial alter for the "common good", I want you to say it."

Most just stutter and ramble and repeat "that's not what I mean" And some, sadly, say "yes...that's exactly how I feel" I then tell them, "congratulations...you have now joined the mindset of the Stalins, Lennins, Mao's, and Pol Pots of the world"

But I think Ayn Rand wrote it best in Atlas Shrugged regarding "The Forgotten Man In Socialized Medicine"

"I quit when medicine was placed under State control, some years ago, said Dr. Hendricks. Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward.

I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything except the desires of the doctors. I have often wondered at the smugness with which people assert their right to control my work, to force my will, to violate my conscience, to stifle my mind. Yet what is it that they expect to depend on, when they lie on an operating table under my hands? Let them discover what kind of doctor their system will now produce. Let them discover in their operating rooms and hospital wards that it is not safe to place their lives in the hands of a doctor whose livelihood they have throttled. It is not safe, if he is the sort of doctor who resents it, and still less safe if he is the sort who does not.

I'm so depressed that I could cry. I've never been a fan of McCain, but Sarah gave me some hope that idiocy hasn't completely overtaken the Republican party. After MaCain's gaff about buying up all those bad housing loans from homeowners, I decided that both parties are trying to out-socialize each other.

I have no hope because I can't afford either party. We make good money, but we don't bring in enough to maintain our lifestyle AND offset what they plan on stealing from us.

I can only pray that none of my family gets sick either. What became of our once-great nation?

thank you all. jennifer, thanks so much for your comment. i did not know there was a character in 'atlas shrugged' who was a surgeon, guess i'll have to read it again. the sentiments expressed by dr, hendricks are my own. i did not do this to get rich. i did this to do a tough job that meant something and to support my family while doing it. now i'm working for bureaucrats who sleep 8 hours a night and make at least what i do. i'm already out of the game, schrodinger's cat is soon to leave, many others are following. this is what results from punishing achievement and hard work. this is why i rail against the current 'loyal opposition'. fifty years ago i think i would have been a democrat. i am not a big fan of mccain but i'll take him 100 times over before i pull a lever for an empty suit socialist who does not have the courage or honesty to tell us what he's got planned for this great country.

Even though our ideals don't always mesh 100%, I usually enjoy reading this blog and I feel that the posts are often intelligent and insightful. This one, however, isn't.

That second video is garbage propaganda, misrepresentation of facts with peppered-in charts to add legitimacy to the whole thing. I know you had some science training on your way to becoming a doctor-- doesn't this crap smell a little off to you? What are the sources? How strong are the connections? How biased are the authors? How valid can the conclusions really be? Its all up in the air. ...Although I admit that the pump up background music does do it's job.

You go on to make some broad generalizations about how things will most definitely turn out, all without any real documentation of the cause and effect us readers can only assume you thoroughly considered. You say this is the way things are going to go? That's fine, but be honest about it. Tell us WHY, and be specific. Without that, this is all just drivel.

Barney "Fife" Frank was sucking the dick of an executive at Fannie Mae (who was living in his Washington home) in charge of packaging the loans for poor people who couldn't afford them, all the while saying there wasn't a problem at all with the Fed-backed company. Why is he getting away with saying all this shit is the GOP fault. If he would have spit the jiz out and spoken the truth 5 and 10 years ago we wouldn't be in this mess.

dear anonymous,What a coincidence! I love your blog too and usually agree with you too! As I am volunteering at a football game tonight I can't really type a full response but I will. And, I know you know this since you are such a regular and all, the idiocy of EMTALA, which is very similar to forcing banks to make bad loans, is explained like, uh... every other post on this blog. Have fun drawing up your 'enemmies' list and go ahead and put my name at the top with a star by it.

dear cynic, i find some stuff about ron paul to like except that he can't win .thanks for the props.

and anonymous, back to the computer. i hope your evening has been filled with hits from your favorite bong and typing away from the cave in which you dwell.

but i'm willing to play, it's true that i have had what some people would call 'some' science training, though my undergraduate degree was in history, so i need some info...

what, exactly, is 'propaganda' and do me the favor of factually refuting the claims made in the video. i feel compelled to point out to you that we aren't talking about science here, but history, economics, and politics, so you caught me there big fella!

the sources, unless my memory fails me, are the washington post, CNN, and others which are all clearly stated in the video. i am so sorry i was mistaken about this but when you put 'money grab' and 'redistribution of wealth' stuff on the table i kinda know that it's not coming from the right so i may be off on this one. it must be cheney or karl rove!

as to the bias and the strength of the conclusions i will let me tell you since you seem to have it all figured out.

as to 'broad generalizations about the way things will turn out' i got you there. all you need do is read this blog and see the comments from physicians all across america who are quitting hospital practice, quitting altogether (like me and 'c at quitting mid career in emergency medicine) and read about massachussets failed attempt at implementing universal health care and i think the result is a foregone conclusion.

here's the deal. you can train someone to stack shelves in a grocery store in a few days. it takes ten years after college to train a surgeon. when they walk out who is going to replace them? EMTALA and the left have made medicine a tough sell to the younger generation. it's too hard a thing to do to have ANY OF IT TAKEN FROM YOU BY LEGISLATIVE FIAT.

Hey 911.....about Atlas Shrugged..it was very small part of the book and with 1000 pages kind of easy to overlook. He lived with Galt and all the other cool kids in their capitalist commune (isn't that any oxymoron).

He examined Dagny after her plane crashed charging her a quarter and, of course, saying his peace.

Just put my GALT/TAGGERT08 bumper sticker on my care...Cafe Press has the coolest stuff :) Oh shut UP! Really? I'm so headed over to Cafe Press right now. There's some guy driving around in an SUV sporting a Who Is John Galt? bumper sticker. I was tempted to run him off the road to find out where he got it. Thanks, Jennifer!

I am terrified that I am going to be screwed because my health sucks lately. I think people who have never had serious health issues just don't understand (unless the are doctors, obviously). I used to count on being healthy and invincible for the rest of my life too. Now, not so much.

Also, why is it that I see people wearing Obama t-shirts all the time, but have never seen one for McCain? My husband and I were just talking about this after our trip to the museum yesterday with the kids. We have a theory on this, but I'd like to hear your opinion.

Obama sucks. He is a wolf in sheep's clothing. Sure he is charismatic, but he is clueless and has very little political experience. He blabs "Change, change, change" but really has no clue how to carry this out. He is definitely not from poor means, he was educated in very expensive schools and never wanted for anything in his life, but he claims to be from lesser means. He has friends in really low places and denies them to the public. I can't stand that fake dweeb! He promises health care to all Americans but has no clue as to how to handle it and doesn't see the big picture. Everyone will fall through the cracks and it will take an eternity to get a simple test done once you throw in all of the extra paperwork that the government demands for anything to occur. He is an empty suit and a dork.

So what is your cure for the health care crisis? I look at McCain's plan and know it would sentence me to bankruptcy and my Daughter to death. No one will insure her, and the medications that keep her alive and sane cost thousands a month. Right now she's covered by my group plan and medicaid. I don't know how long I'll be able to keep her on my plan, as she has to be my disabled dependent to qualify. I hope that eventually she will be able to get a job in the community and live more independently. With the current state of diabetes care and her learning challenges, she will never be able to manage her diabetes care without help. I also know that no job that she would be able to do will provide her with the kind of health insurance she needs. I struggle to find doctors willing to see her because her secondary insurance is medicaid.

As a minister, I'm in and out of hospitals all the time. I know our current system is broken, but how would you fix it? How would you assure my 21 year old daughter gets the health care she needs?

I have a job-- more than full time. My daughter may be able to work at McDonald's some day. She wouldn't earn enough to pay for her prescriptions, even if she continued to live with me, I wouldn't be able to help enough to keep her healthy and us fed and a roof over our head.

dear reverend mom, why do you think she will not be covered under mccain's plan? tough cases make bad law and if your daughter is, say, a down's child, then there is no one trying to take her coverage away. all we are saying is that everyone is responsible for themselves. let me ask you this, why do you expect other people to pay for your daughter's health care? they do already, but why do you think it's right?

but besides that, we are not talking about exceptional cases here. in my decade plus experience in the ER my quarrel is with otherwise able bodied individuals who have made, and continue to make bad choices, and expect YOU to pay for them.

the American College of Emergency Physicians estimates, and they are a liberal organization, that each emergency physician in America gives away $150,000 in 'free' care a year. we can not deduct it on our taxes. we are taxed in the hightest bracket, AND, for these folks we take care of for free, and they are often in the country illegally, we can still be sued for malpractice. again, explain to me how this ENCOURAGES personal responsibility, or do you not believe in that concept?

obama care will wreck our system by making health care a 'right' and doctors will vote with their feet out the door. then you will be in a unique position, your daughter will be fully covered, but she will have a hard time finding a doctor in a timely fashion. care will be rationed. good luck.

Reverend Mom, enjoyed your Blog, but couldn't resist offering a few suggestions, cause that's what I do.1: You ate at a Mexican Restaurant for Lunch? Generic Refried Beans are 79 cents at Walmart, know you wanta do your part to support undocumented workers, but every cent helps.

2: Your daughter Bowls? How much Metformin could you buy with her Lane fees? Take a tip from the Mexicans and play soccer with an old tennis ball on the tennis courts noone uses anymore cause of all the Mexicans playing soccer.

3: How much did you pay for those Mexicans, I mean guys to wash and detail your car? I still do my own, but that's cause I'm a cheap ass doctor.

4: You and your daughter both have cell phones, oh yeah, thats a right too. I didn't get a Cell Phone till they totally got rid of Pay Phones, but thats just cause I'm a cheap bastard.

This is my first post here, but I enjoy your blog greatly. After the Reverend's post, I couldn't restrain myself any longer. I am disabled, permanently and legally through Social Security. I have a form of muscular dystrophy and continue to fight every day for a new way to make a living. You mention your daughter could work for McDonald's but she might not earn enough to pay for her medications........or would she? If she worked full-time, she would get health insurance benefits. Heck, even some of their part-timers are eligible for insurance! McDonald's benefits have been pretty good in the past - sure they would still be now, since they are always trying to get help. Maybe if she had a job that had insurance, then her prescriptions wouldn't cost an arm and a leg - and she'd have a $5 copay for Metformin, like my husband. But then, maybe you feel she can't hold a job. If so, why haven't you tried to have her permanently "disabled" through Social Security so that she would be on Medicare instead of Medicaid? Sure it takes 2+ years to be approved, but if you have a genuine need, then why not? We also have 2 homes in our neighborhood that are Disabled Citizens owned homes. They have up to 8 different disabled citizens with full-time round the clock aides. These aides take care of them and drive them from/to their jobs. There are options for your daughter. Maybe instead of playing the "poor me, I've got it so horrible" card, you could actually use that energy toward something useful. But, you probably love Obama, and are hoping for a full round of hand-outs. Best of luck on that - since it's worked so well with Fannie-Mae and Freddie-Mac and the low-income folks being able to stay in their homes.

To the McCain/Palin lovers: Are you folks nuts? Have you not seen what the past 8 years of republican rule has done to this country and this world? What part of overspend, corrupt,torture, war-waging, deficit building, demolished economy, demolished environment do you not understand? You have made this world a disaster zone. Please stand aside and let someone try and clean up your mess. It will be very difficult thanks to your policies but at least we have to try! This is not a novel. This is not just about your damn pocketbook. This is failed policy and ignorant leadership.

Wow! I don't think either duo has a slam-dunk plan for fixing the healthcare system, but it's hard to hear that 'cause I'm not a fan of socialized, rationed healthcare, *I* am personally responsible for the mess this country's in! I'm digging the discourse too, but let's be careful not to miss the point...

Experts think there will be less employer provided group insurance. In my neck of the woods group insurance is already disappearing. My daughter will never be able to qualify for individual coverage. She is covered by my group insurance and Medicaid. Because her secondary is Medicaid, I have a very difficult time finding doctors who are willing to take her on. I drive up to 100 miles (one way) for some of her specialists.

I think everyone should have access to medical care. I don't think it should be free, but I also don't think that it should be so limited that it causes someone to go bankrupt, or do without needed medication. While you see the people who take advantage of the system, I see the people who choose not to treat GERD or Type 2 diabetes because they can't afford the medication and their insurance won't cover it. I see the woman who works more than full time for a company that doesn't provide insurance and pays just over minimum wage. Because of pre-existing conditions, she can't get individual coverage. I see the family who drops their son's individual coverage because it won't cover mental health care or his anti-psychotic medication, and his farm income is so low that the insurance agent told them he won't have to pay for his care so he might as well stop paying for insurance because it wouldn't cover what he needs.

So how would you fix this system? How would you see that people like this have access to care without relying on free care or going bankrupt?

frank,

1. I have budgeted for us to eat out once a week-- on Sunday's for lunch because I like to sit down and relax before jumping into the evening activities. We eat at the cheapest sit down restaurant in the area. I don't ask to see green cards before I order. Sorry.

2. We pay $4.50 8 times a year so my daughter can bowl two games with special olympics on Sunday afternoons. That wouldn't cover a single vial of her lantus, let alone her novolog. My understanding is that metformin doesn't work with type 1, so I wouldn't know what it costs.

3. I get my car washed about 7 times a year-- I won't pay for detailing and wax. Oh, and there wasn't a Mexican in sight at the car wash. Until I moved here, I washed it myself. My well water is so hard and full of sulfur that without extensive treatment it won't wash anything. The water to the outdoor spigot isn't treated. This is the first place I've ever lived where you don't see people out washing their cars. The water is that bad.

4. About those cell phones: there are people who needed to reach me in emergencies, and since I don't sit at home or in the office, I can be very difficult to reach. The school wanted to know how to reach me, too, for times when my daughter's blood sugar dropped too low or she had a seizure. I got the cell phone for my daughter after she got left behind twice at track practice at locations miles from home and school. Yes, I did have words with the school about that. But I also couldn't have my daughter with type 1 diabetes alone without access to a phone 12 miles from home, especially when she had just finished heavy exercise. If I want her to participate in normal activities, she needs to know that she can reach me when she needs me.

Sorry you don't approve of my lifestyle choices. You probably think I was dumb to adopt a kid who had been raped by her family at age 2, as well. I should have known I was setting myself up for heart ache and expense and left her in the foster care system.

Anonymous,

My daughter is on SSI, but I continue to hope she will be able to work, which I made very clear to them when we applied. I don't want her on permanent disability-- I want her to keep learning and growing until she reaches the point she can work. I intend to keep pushing her. She is supposed to be working on job skills at the sheltered workshop so she can get a job in the community. They haven't been doing the best job of that, though her case manager and I continue to try to educate them on what to do with her. Despite my efforts and the efforts of her diabetes team, they still treat any blood sugar below 120 and panic.

She's on a list to get into one of those supported living situations you describe-- there is a 10 year wait. Oh, and those aides you talk about helping the disabled citizens? They're paid for by medicaid. So as long as I can keep her in my home, I will.

I'm not seeking handouts. She's not getting the full amount of SSI because she lives with me. I could charge her rent and have the SSI increased, but I have chosen not to. In a few months, she'll be eligible for food stamps, but I don't plan on applying for them.

Sorry if you think I'm playing "the poor me I've got it so horrible card." That's not my intention. My intention is to point out another perspective on our broken health care system.

It's interesting to me that people who support requiring employers to provide health insurance always back up that belief with examples of where having a lot of people insured by employers actually made insurance more difficult or costly to obtain in their case.

Basically your argument is, if an idea doesn't work, then we need to do more of that idea. Like they used to say to us at work, "the whipping will continue until the morale improves."

You need to take a look at Dr. Bernstein's Diabetes Solution for your daughter. Eating high carb meals like Mexican food makes it incredibly difficult for a Type 1 diabetic to keep their blood sugar level. You can read most of his book for free online. You also need to ditch your dietician. Fat is not the enemy when it comes to glucose control.

Bla Bla Bla Reverend, don't you have a sermon you should be workin on? All I know is when I didn't make my car payments a Bad Man came and took her away from me. No ones gonna take your Daughters Lantus, and oh yeah, those $5 glucose tablets, theres something just as good for 1/2 the price, they're called "PEZ" and even come with a cool dispensor.

last time i checked george bush was not running, mccain has been a thorn in his side, and what we have in iraq is a victory, and one soon to happen in afghanistan. the subprime mess is at your party's doorstep you colossal nincompoop. you expect me to vote for a senator who had his biography ghostwritten for him but won't admit it, votes 'present' 9 times out of 10 in congress, won't define what 'change' he's going to bring but does in fact associate with bill ayres(who thinks 9-11 was great and felt his bombings in the sixties were 'not enough') and is dirty with money from america haters AND his wife is an American hating banshee? he's telling me he's going to raise my taxes and make me a government employee and you want me to vote for him? you are a socialist. go somewhere else you irritating, shallow thinking, knee-jerk, know-nothing. you are embarrasing. in fact, if you like socialism so much, move to fucking europe. obama is a conveniently colored empty suit and would never be where he is today if he were not African-American. i almost feel sorry for the guy, editor of the Harvard Law Review and never wrote a scrap? never worked a real job outside of politics? you want him and that bumbling idiot Biden? sheesh. i wish i could meet you so i could slap your sorry face and see if you had the guts to hit back. in fact, i'll give you one for free... right on the chin. free shot. pussy.

I have acknowledged the current system is not working. I have expressed concern that a plan that relies on individuals buying their own policies may exclude those who most need insurance. I have asked what the solution is for fixing the problem. No one has offered a plan. There have been plenty of personal attacks on me, but I have yet to see a proposal.

The alternator on my wife's car is going out. She needs her car to function ( take the kids, help with the business, etc.) This is a need she has, but the GM repair shop said it wasn't a right and wanted me to pay for the alternator. Does anyone have a solution to this alternator crisis?

I just love it when the owners of this blog get all huffy over the comments: people with a short fuse are funny; insults => red faces, shaky hands, throbbing neck veins... It is tempting to throw in my two cents on the topic again but I think I'll resist and just sit on the sidelines and watch the entertainment instead. Much more enjoyable. :-)Drackman: People are not impressed by bimmers. Up your game. Just a friendly tip.

if Obama's gonna raise your taxes then you must be making at least $250,000/year, good for you. On the other hand if you believe that the next president won't have to raise taxes then you just haven't been paying attention to the economy my friend.

perhaps you didn't here of the 840 billion dollar wall street bailout a mess both parties are responsible for. or perhaps you missed to 25 billion dollar auto bailout that passed so quietly a the week before as well. Oh and lets not forget the billions of dollars spent in Iraq so as to protect YOU and the American people from further terrorist attacks, and a national debt in the trillions. It really is simple math my friends (you do remember simple math right? if the money coming in is less than the money going out there are only a few things you can do. stop all the money going out or start bringing more money in, and the next President is going to have to do BOTH), and its got to come from somewhere so its gonna come from the American taxpayer no matter what any of the candidates say.

OK,Amy, its a BMW JET, well not really, and as far as BMW's not impressing people, tell me about it. $45K, and I'm getting smoked by toothless hicks in 89 IROCs, I'm more impressed by my Wife's $500 shoes. How about that SMART ASS, You Spend that much on SHOES?!?!? Sorry, I'm a little out of sorts today.

Oh yeah, Mark, I checked out your blog, you're the worst of both worlds, an INTERNIST and a SCIENTIST, I understand why you're pissed at rednecks like me, I bet the real Mark Trail makes more than you do. Want to know the best thing about the tax code? When I hit around the $100k mark(not until Sept this year, unfortunately) I get a %15 tax cut, cause that effin FICA y'all commies love so much goes away!! So put that in your Grateful Dead Bong and Smoke it!!! Sorry, I get this way when Auburn loses 2 games in a row.

mark, how much should i make and how much should i pay in taxes. up until i quit the ER four weeks ago i worked about fifteen shifts a month, four of which were overnights, and saw all comers at all hours. i have been confused about how much i should have made, so im glad you can help me here.

as to the 840billion dollar mess on wall street i'm not sure how the conservatives who tried to reform freedie and fannie get the rap for this one, again, based on the video and other sources.

finally, i know i'm stupid because i'm just a normal MD and not a scientist and all but i seem to recall instances in our history where politicians with a smidgen of cojones and common sense have cut taxes and watched the revenues to the treasury soar. seems there's a little thing about incentive for achievers and all and a willingness to pour money into the economy if you know you aren't going to have to give most of it to the government to pay for their cause du jour.

and as to the war, every one of my friends who has been there think you are wrong. i think you are too.

I think everyone should have access to cheaper books. $15.99 is too much to pay for a book, so I think publishers should lower their prices to $3.00. Do I care that the publishers are actually out of pocket for every book and will probably go out of business? Hell no! I have my rights, dammit.

But what am I gonna do when all the publishers go out of business? Then where will I go?

Come on, you libs! Are you that thick that you don't understand the laws of supply and demand? You cannot insist on forcing people to work for free just because you want it. It's called personal responsibility and preparation. You people will force the industry to implode. Hospitals will close, and docs will leave medicine. Those who remain are people I wouldn't let trim a houseplant let alone a tumor.

mark, the reason i'm evil enough to make over $250,000 is that my wife too, is a professional. combined we do get into the 'evil' category. this is after delaying family, home buying, and children for about 8 years versus starting say, as if i had gone to law school. if obama wins our strategy is this...

work half time, become 'un evil' by making just under 250k, fire our three day a week nanny, and relax. pour money into the market as it has oversold in a panic cheered on by the left, and wait for people to figure out that obama will be worse than carter and we swing back to more market based solutions. again, if someone could simply point out one country that has done anything other than freeze its social classes and ration health care under an obama type socilaism then i'll reconsider this plan.

and reverend mother, the whole point of my argument is this, nothing is smarter than the market at efficiently distributing resources. no committee can do it, no government bureaucracy can do it, that is the genius of the market. your questions are all self centered. you worry about you and your daughter. i worry about our country. you think that by taking from folks like me that things will work out fine based on your definition of fairness. the thing you don't understand is that folks like me will decline to participate.

good luck with your free health care, it will worth exactly what other 'free stuff' is worth. shit.

holy shit. this gets better and better. under obama care my family and i are covered. scratch my $700 a month insurance premium. sweet! i can petition the VA to increase my disability and i can't see how they will turn me down given my fibro and all. pretty soon there will be govt. subsidized child care too, that's one more thing i'll get. if i can simply get a job with the VA or perhaps go back into the guard or reserves then i can get my pension in ten years or so. obama will not deploy troops anywhere except israel so i'm good there too... no one shooting at me and all, and to top it all off, when his administration figures out that doctors are quitting i'll sign on to run some rationed-care clone of the VA and work for more money than i make now, half time, and send all the difficult cases to whatever clueless idiot doesn't get that he's losing money on my patients. my liability will go down and his will go up... i'm diggin' this. i'm set!

you see, however much you hate successful people, they are successful because they work hard and plan efficiently. i don't know why i've been against all this! finally, an 8-5 job with full benefits and a bonus which, to get enough doctors to bite, will not be taxable! awesome! if i can just get someone on the left to figure out a way to mandate 'affordable housing' i can get into a home three times my current one's size for less than i pay for this one (3800sq ft and worth about 380k).

Thanks for the post. Why aren't more people talking about this and getting the facts out to the public?

The scenario you describe is both disturbing and frightening and I'll add discouraging.

I have to believe someone will use their common sense.

I still say the medical community needs to unite and make there views known...using every medium available...to be heard by all.

There has to be an informative grass roots movement that ignites into a firestorm across this country regarding the effects of EMTALA and all plans or proposed plans that will create an even deeper health care crisis!

Most people aren't reading medical blogs. You just don't read about these things in the papers or hear it on the news.

People grumble but don't actively do anything about it and so their concerns are buried or snuffed out by the people with the power and the voices.

if i can just get someone on the left to figure out a way to mandate 'affordable housing' i can get into a home three times my current one's size for less than i pay for this one (3800sq ft and worth about 380k).

The left already tried that, remember? And that's why we're now in this stinkin' bail-out mess.

Someone above is trying to blame the bail-out of Fannie&Freddie on "both parties." Sorry. This is one that belongs to the Democrats and their cronies. Too bad the non-partisan public doesn't know that, because the leftist mainstream press/media is never going to let that be widely known. You can bet if this were a Republican mess, the press would be all over it.

Hey Lynn... you should collaborate with the medblog docs and write a scathing expose of what these current regulations are doing to harm the system and as well as what the future may hold with a government subsidized health care plan.

There have to be regulations for quality/optimum health care... and should always strive to improve patient care, etc., but eliminate the superfluous regulations implemented by the pencil pushers who know nothing of working in the trenches. Didn't one of the docs here have to take some class on how to obtain a stool sample and learn the new requirements for performing said procedure?

But of course there are problems of a much greater magnitude. It's all too big. And then to grow the system even more with a government run system?

I say scathing... factually scathing because that would get the attention of the talking heads. It needs to become a HOT topic!

Also... though... feasible working solutions to fix the health care solutions need to be included.

I think a number one NY Times best seller could be just what the doctor ordered. :)

Listen, I realize I'll never win an argument with y'all or change your minds but as a Critical Care Doc I have had plenty of dealings with ER physicians and have a very good working relationship with them. Don't hate on me because I actually enjoy what I do for a living.

Going back to the Rev. Mother - I just don't get it. You cry "poor me" and "my poor child" and yet when you are given opportunities to help yourself and your child, you shun them and then ask why everyone how they are going to fix a "flawed" system. You have the opportunity to have your daughter declared "permanently disabled", and get her both the full financial assistance she needs, Medicare (instead of Medicaid), as well as full access to job-training skills and thus allowing her to get a job and live independently........and yet you do nothing except bemoan your circumstance. You have the ability to accept food stamps to help not only reduce your food expense, but to feed your daughter a healthy diet and help her Type 1 diabetes (and maybe reduce her need for so much medication and ER trips) - and yet your pride is so great that you refuse.......and bemoan your circumstance. There are obviously changes needed in the system so it doesn't take 2 years to obtain the legal "permanently disabled" status, as well as many other bureaucratic pitfalls that suck up the disabled into a paperwork abyss, but if you think that having the government tell doctors and hospitals how, when, who and what they should treat/charge is going to work - then you are completely and totally delusional. From an "outside looking in" perspective, you are the type of person the democratic party LOVES. You decry everything, but when there are already measures in place to help you, you refuse them. As a 'Reverend', you should know that God helps those who help themselves. There are many helping hands out there ready to offer you assistance, you just need to shut up, swallow your misplaced pride, and accept the help available instead of wallowing in the giant cesspool of self-pity. Government run insurance doesn't work - I've seen many, many cases of people from Europe and Asia coming to the US to be treated because the wait list for back surgery, hernia surgery and many other things is YEARS upon YEARS. The government never makes things easier - they just muck it up royally - and add a mountain of paperwork - thus depleting the trees in forests, which then contributes to greenhouse gases and depletes the ozone layer! lol..........

i would love it if you would come and work at my former hospital. got called to a code there two months ago to intubate a patient for the pulmonologist who was standing at the bedside.

i don't know in what setting you practice, if you live in a smaller city then the hospital is lucky to have you. in my town of nearly 300,000 we lack urology, trauma, peds surg, neurosurg, neurology, psyche, endocrine, rheum., and a few others.

the specialists are fleeing to the protection of large cities or academia. i find myself now with a dwindling number of options to get definitive care and our EMS system is broken.

people are starting to die needlessly and i believe it is, in almost all cases, a direct result of EMTALA and, as i stated in the post, EMTALA is a lot like the subprime mess. the solution CAN NOT BE to insert MORE governmental control, look at the VA for goodness sakes.

911doc I have been an avid reader for quite a while and enjoy both the medical and non-medical posts although I don't always comment.

Even if I don't always agree it provides a nice perspective to view other peoples opinions.

Having said that I very much agree with the EMTALA problem and it is becoming more difficult for any Hospital, particularly with an ED, to operate given the multitude of problems.

The next problem on the horizon is the RAC or Recovery Audit Contractors Program. Designed solely to get more money back to Medicare/Medicaid its only mission is to go through hospital records and determine if a procedure was medically necessary or not. If they deem it not necessary they demand that the hospital pay them back for the procedure. I heard recently that a Florida hospital fought the decisions and recovered over 70% of the initial fees taken. On the other hand it cost them almost as much in legal fees to do it. If you Google Recovery Audit Contractors you'll see what I mean.

Not to turn this into a lovefest because I realize we have fundamental differences in our political views (your latest Beatles post included). But as a Fellow in training we used to cover a local community hospital ICU and we were also responsible for any 'floor emergency' including running all codes. One night I was called to see a 350lb + woman in florid (pink frothy sputum from the mouth) CHF. She clearly needed to be intubated but I was nervous due to her size. As respiratory bagged her and I prepared to sedate her I asked the Nursing supervisor to call the ED Doc to the floor, just in case. Luckily I was able to follow the trail of pink froth all the way to her vocal cords. A few months later I was called to the ED for a difficult intubation that ended up being successful as I walked in the room. My point is, it is always nice to know when someone is there to back you up.

I look forward to the future when you or your colleagues may call me a pyocephalic liberal lovin' commie.

Mark, thats scary when Internists are doing intubations...oh yeah, Intensivist, Internist with 2 more years to learn about obscure diseases...a few Anesthesia Intubation Pearls, 1:Sedation?? if someone can keep you from puttin that tube in, they probably don't need it. 2: If you really need sedation, hyperCarbia does wonders, pCO2 of 80 is equivalent to breathing 60% Nitrous, Cops use it all the time to "Sedate" people. And its free and not controlled.

Frank, 1) if you think that sedation is not needed for some intubations then I pity the patients you care for and hope I never land in your ED in respiratory distress.2) Since you weren't there I'll just chalk it up to my not providing every detail of this patients clinical condition.3) Not everyone who needs mechanical ventilation becomes hypercarbic. ie a young patient with pneumonia and a high work of breathing can maintain a normal CO2 for a long time. It doesn't mean you should wait until they're acidotic to intubate them.

Ha Ha Mark, just bustin balls, but you should really check out my blog sometimes. 1: Not sayin gettn tubed is pleasant, but gettin dead is worse, last time I checked "S" for sedation was after ABCs, but thats whats great about America, different strokes for different fokes. 2: Acidosis is GOOD, pushes that Hemoglobin Curvey thingie to the right, enhancing O2 delivery to the tissues, shouldn't you be able to talk for 5 days about this, bein an Internsivist and all?? 3: Was that in Insult? Boring Articles at 10 paces!!! 4pm in the Vegetable Garden! I mean Stroke Unit,

Lesson 1:I did not call you names because I am not coward enough. If I would not insult you in person, I am not going to do it at all. Period.And obviously, from your reaction, I can tell I could make my point across just as well without name calling.How about "I am going to wax the Ki-a Ri-o"? Uh?Lesson 2: You cannot compare $500 shoes and a car.When I find a car that makes my legs look longer, makes me look slimmer and taller while adding a pinch of sexiness, I'll buy it to impress. In the meantime, I'll stick to the high heel pumps. Furthermore, your wife is (always)right, but you already knew that. ;-)

911,Simply an outstanding post. I have just purchased my Galt/Taggart'08 bumper sticker and am on my way to the store to buy a few copies of Atlas Shrugged. My old copy is in pieces and I want to refresh my memory about what life will be like if nobama is elected.

As an expat American doctor who has trained and worked only in socialised healthcare systems (first Ireland and now New Zealand), I'm a little confused about why socialised medicine is seen to be such a horrendous evil thing?I don't see terrible care happening anywhere as a result. In NZ where I am in cardiology (as a junior) at the moment there is quick timely access to primary angioplasty 24/7, we are using intra-aortic balloon pumps and having better and better outcomes, and everyone here seems to live longer than Americans (or Irish for that matter, must be all the booze :) ) Here no-one worries about having to afford healthcare-everyone who is resident or a citizen gets all healthcare free. We practice evidence based healthcare and people are seen and treated in order of clinical priority. To me it seems they are treated in a timely and efficient manner. When they go home the hospital pays for their transport and there is a " Meet and Greet" service that is community based RNs who settle the patient into their hom, turn the heating on, go through meds etc when they are first discharged. If you are working and become ill, a Government body called ACC pays you 80% of your wages until you recover. Yes, taxes are likely a little higher here than in the States (some states anyway), but no-one worries. Why spend all your time killing yourself concentrating your personal wealth? You have a good quality safety net. There are really good doctors here, and recently NZ has had a huge influx of doctors as the working conditions are much MUCH better than in most of the rest of the world, especially for juniors. We are not paid badly, as some think.

Actually, when I worked as a junior doc in Ireland, we were paid an awful lot more than USA interns and residents. Irish consultants too, make more than American ones.

Why would it be such a bad thing to have healthcare funded and paid for for everyone, by everyone? It doesn't mean that we are all red Commies and that the economy will collapse.Actually, NZ's economy is vastly more stable than the American one at the moment! They are even proposing universal funding of college students so everyone who wants it can get a good education. And tax cuts.

Taking care of your citizens over the longer term is actually cost effective.

america is not a socialist country. as for your economy down there being more stable than ours at the moment, you are probably right. the US economy is in trouble right now because of a socialist scheme to make owning a house 'affordable' for everyone. it's simply not. however, our economy IS the economy that drives the world's economy and you have us to thank for that, for most technological advances in the last century, for most of the refining of medicine and surgery in the last century, and for your freedom from Japanese domination in WW2. if you don't believe me go read about the Japanese island hopping down to New Guinea and to how many American servicemen were deployed to NZ 'just in case'.

i'm not taking credit for any of this, i have benefitted from it, what i'm saying is that NZ, like the scandinavian countries, is a far different cup of tea the US, where our border to the south may as well not be a border, and where we still manage to do the best surgery and medicine ANYWHERE.

one of your colleagues, dr shroom, who is in england, opined six months ago that at his cardiology center just outside of London that after 5pm there was no cath available for anyone. it's all lytics after the doors close in england. i'm a bit incredulous that you have 24/7 interventional cardiology in NZ as we do here, but i'll have to take your word for it.

as to how easy it is for one born in poor means, by hard work and effort, to elevate themselves the socialized countries that "APPEAR" to make it work tend to have, well, three thousand miles of ocean around them and have dumped their armed forces because they figure if anyone comes suicide bombing their way then the good old yanks will step up and come to the rescue.

your system must have changed in fifteen years as my aunt, a native new zealander (though at other points in the blog i've claimed that she was from England for the purposes of anonymity) was diagnosed with multi-vessel cornary disease at age 71 in NZ. she was to be medically managed.

she came here and paid for a bypass and lived another 15 years. her doctors in NZ gave her one to two years with medical management.

i am not knocking your skills or those of the other fine docs down there, but yours is a rationed care system and it is not taking care of , conservative estimate, twenty million illegal immigrants and passing that burden on to the docs and taxpayers.

as to cradle to grave 'guarantees' re education etc.... i'm wondering who pays for all this? also, i'm wondering why you think...

1. the government is more efficient than the individual at properly divvying up resources and

2. why, say, a childless couple should be expected to put in the pot to fund other's educations.

at bottom you are advocating socialism and that's fine, it's a lot more courageous than the anonymous nincompoops who come on here and talk about 'fairness', but your country is a bit unique in it's isolation, it's bountiful land, and mostly homogenous population.

as you know we pride ourselves here on being the land of opportunity. when i want others to do what i should do for myself maybe i'll come on down and kick my feet back a bit. and one last quibble, you might get our animosity towards the solutions you seem to like if you simply took a new perspective.

"the government" has no money. it does nothing to bring in money, and is funded fully by taxation (with very small exceptions).

when "they" are going to put folks through college "they" are going to take money from one group and give it to another. the difference between our countries at the moment is that the taking from one group and giving to another is not as great as it is in NZ.

but who's right is it to tell me how much i make and whose right is it to take my wages and give them to others? here, after taxes, it's nobody's damned business, and, in fact, business is terrifically more efficient at squeezing the maximum benefit out of a dollar.

i am not surprised to hear that you are a fan of the system down there, but please do answer who decides who will be allowed to get life saving surgery and what is the cut off for 'heroic measures'? when, with multi vessel disease, does one fall out of the bypass option and into the medically managed option? i want to make that decision for myself and my family, God bless ya if you trust someone with a clipboard to do it.

'taking care of your citizens', sorry gina, just read your post again. what in God's name do you think we do over here? we take care of our citizen's and millions of illegals and do it all immediately. and since when did personal responsibility go out the window? are the kiwis so daft that they have to have everything spoon fed to them? last time i was there i know the economy was in the tank and much of the cradle to grave stuff was at least trimmed down a bit but wow, you guys have evidently invented the perpetual motion machine.

'taking care of your citizens'. who are you, the Pope? and do tell how it's 'more effective in the long run', what exactly are you talking about, going into people's homes and stubbing out their cigarettes and knocking the beers out of their hands?

i don't know which is worse, a government as intrusive as the soviet/east germans were and stockpiling weapons and plotting coup d'etats in other countries, OR, a government that sends someone by each night at 9pm with a warm cup of milk and a blanky.

it is most certainly the LEAST COST EFFECTIVE WAY POSSIBLE to do anything... running it through the government middleman. how about this, we round up say, ten million illegal immigrants, ship 'em down to you, and let you take care of them. i say if you guys have it figured out so well then by all means, let's send those left behind by our obviously uncaring government right down to you! i'll start spreading the word.

"taking care of your citizens'. who are you, the Pope? and do tell how it's 'more effective in the long run', what exactly are you talking about, going into people's homes and stubbing out their cigarettes and knocking the beers out of their hands?"

Ummm, okay....

Just because a country socialises healthcare and social care doesn't mean they are terrifying, 1984esque red Commies who control your every move. Kiwis love their beer, and make a bunch of amazing wine. Everyone down here enjoys their liquour. And smokes if they want to. And skydives if they wanna. And base jumping. And does anything else they feel like doing.

I'm not trying to piss people off or start anything, I guess I just find it interesting-I am an American and could have ended up living and working there, and maybe feeling like you guys, and instead have lived and worked in countries with mainly socialist healthcare systems. I just don't understand what is supposed to be so bad about them. From a doctor's point of view, I'm paid well, never work more than a 15 hour shift, and have as much paid sick leave as I want. A lot of our paperwork and results etc, have been computerised now, and stuff is faxed or emailed instead of physically represented on paper, and hence a lot of scutwork has been eliminated. Also Kiwi docs cannot be sued! No fear in my job. ACC that I was talking about compensates victims of medical mishaps or even victims of recognised complications and provides domiciliary assistance if they need it for free. We can be open and honest with patients and there is generally a pretty good vibe around the place.

911doc, I'm sorry about what your aunt went through. Certainly I have not seen similar cases, though I work in a large tertiary centre in a city and hence am probably not likely to witness as much mismanagement like what you describe as I would if I were working in one of the more peripheral isolated centres here. It is true in the tertiary centres in the cities here, we do indeed have access to 24/7 cath lab and primary angioplasty. We are increasingly getting more air ambulance transfers from smaller hospitals and hopefully this means that less mismanagement like what you describe happened to your aunt is occurring as more and more doctors recognise the need for early intervention.

The way things are in the UK is crap, I agree. They have taken the control thing too far. Brits tend to do that for some reason. However, NZ healthcare is vastly different to UK healthcare. Many UK docs that have fled the system have come down here now and are not going back. Ireland also is not part of the UK, the Republic of Ireland has it's own distinct government and healthcare systems. Hence the unfortunate events that have unfolded recently in the UK are not affecting the Irish.

I am confused about the illegal immigrant situation in the USA. On one hand, there is apparently no universal healthcare and millions are without healthcare. On the other hand, you say they are being taken care of and are draining your resources. How are they accessing healthcare in the USA and hence depleting those resources if they are unable to? Do American docs have a legal obligation to treat nonpaying patients? I genuinely don't know what the situation is in that regard. If you have a legal obligation to treat millions of illegal immigrants in a nonprofit capacity when you are remunerated on a per patient basis, then I can understand a little why you are annoyed.

I think the situation in America is probably more complicated than it is here, and I agree with you on that score. I don't know how that can be resolved. It just seems like everyone that I talk to from the States is obsessed with making money and keeping money and fuck everyone else, and having no experience of the system and only really holiday experience of the country I am a citizen of, I don't understand why that is so. I'm a doctor, I make a decent living, and in the event of the shit hitting the fan I have a safety net. Good life. I couldn't imagine being obsessed with holding onto every dollar I earn, I earn enough to be comfortable, travel, buy what I want, live where I want, drive the kind of car I want. It doesn't seem like Communism to me.

If America was the only country in the world, say, would you think differently about taking care of the citizens in it. By taking care I don't mean sinister Orwellian concepts. I mean providing good quality easily accessible free at the point of entry healthcare. Social support for those who genuinely need it-on a means tested basis and with the condition that if they are deemed able they make legitimate attempts to get back into the workforce. Financial support so that hard working people who pay their taxes are not financially destroyed by developing cancer or a debilitating condition. And yes, funded by taxation to a large extent. With no defense or army or wars there would be no huge military budget.

The taxes here are high-but not crippling. The taxes in Ireland weren't crippling either.

You see the bad side of the coin as pertains to socialised medicine.

NZ docs talk about how in the States, docs have to do unnecessary investigations and procedures to make more income for the hospital or insurance company or whatever, and expose the patient to the risks of same. That's what we see, that and people not getting healthcare because they are not wealthy. I think your version of socialised medicine is not accurate, and our version of "capitalized medicine" may also not be accurate. I would love to know more about it, and I genuinely don't mean to cause offence to anyone by sharing my experience oropinions. It's just a different world to the one I live in, and I don't really understand it. The people who live in it sound angry, bitter, not compassionate or humanitarian, and I wonder why and how things could be so bad for you all that you sound this way.

There is no universal health insurance in America. The only people who suffer here are those who choose not to seek treatment for one reason or another. People who are not illegals are still on the hook to pay, unless they have managed to secure Medicaid. Illegals and those on Medicaid receive medical care in the Emergency Department for free. Both of these groups have large numbers of people who abuse the system. It may not be 100% of those people, but it's enough to create a burden on the rest of us.

If you had massive numbers of illegal immigrants whom you were required to treat without pay, your system would be in much worse trouble than the American system. Fortunately for you, I guess millions of poor people are not wanting to come to NZ.

sorry i got a bit miffed. i think you are new to our blog so let me summarize and repeat my one question to you...

what happens to the 70 plus year old crowd in NZ who need bypasses etc... is there an age, after which, life prolonging procedures are rationed. my aunt did not get poor care, she just could not get a bypass because she was outside the window for age.

as to our situation here it goes like this...

when medicine was more market based we had great care for everyone whether it came from a charity hospital or whether someone had insurance. prices for care were reasonable and insurance was not hard to get.

in 1986 congress passed EMTALA, which, ostensibly, prevented one hospital from 'dumping' a patient on another hospital for inability to pay.

they did not, however, fund it, and they did not define what an 'emergency condition' is.

also, there were no provisions in the bill for collecting from foreign governments whose citizens, many times, would cross the border specifically to have their babies born in the US and thereby gain US citizenship.

so, EMTALA was just like the subprime mortgage mess where the government forced banks into making loans they would not otherwise make.

just as over 5 million illegal immigrants bought houses in the US because of the Community Reinvestment Act as modified by the Clinton administration, everyone has figured out that going to the ER is 'free'.

We have tried to cut these ER abusers out by rewriting triage protocols and defining 'emergency' ourselves but none of these attempts to stem the flow have been allowed by the courts.

When health care is 'paid for' by the government it is 'paid for' by increasing taxes. The way Obama wants to do this is by increasing taxes on folks making over $250k a year.

This has never worked anywhere. The revenues will actually decrease with this tax structure because folks like me will simply work less, dump our private insurance, and, in general, our economy will slow.

This is not a guess, at the end of the Carter administration the top earners paid over %70 in income tax. We had inflation, stagflation, and a 'misery index'.

Reagan came in and cut capital gains taxes, income taxes, and windfall taxes and within five years the economy was booming and the jobless rate (12% under Carter) was below 5%.

And the illegal immigrant problem IS huge. I have no quarrel with folks wanting a better life and risking their lives to get it by crossing hundreds of miles of desert... My problem is that we can only absorb so much, I hate to point this out to people but coming into any country like this is illegal and will usually get you deported.

I can't go to Mexico and buy land, I can't go there and work, and if I snuck in illegally they would either put me in prison or kick me out. It is amazing to me that many Americans don't seem to mind that tens of millions of illegals have stressed our excellent system to the point that we are considering a socialized medical system.

We already have one, by the way, it's called the Veteran's Administration, and it's where I get my health care. It is fine as far as it goes, but when I make appointments for procedures or studies like an MRI the wait is three to nine weeks. If I simply went to the ER with my insurance I would have the study done within 24 hours.

This doesn't usually matter, but, as you know, it DOES matter many times with folks at the extremes of age. That's why I'm interested what would happen to my aunt if she was in New Zealand today. Her multi-vessel disease would be diagnosed, she would not be a candidate for stents, and I want to know, at age 75, if she would get her bypass.

911doc,Thanks for the clarification. It still sounds bloody complicated! :)

In regard to what happened with your aunt: There is definitively no age threshold above which NZ docs do not treat people. Indeed, this idea would be against the principle of socialised medicine, if you think about it! I don't know what happened. I simply don't have the details. I feel bad that she had a bad experience and that it has put you off the idea of government funded healthcare for citizens, but there simply is no age ceiling like that. Did a doctor actually, physically tell her that "You are above the age at which we bypass people?" I find that hard to believe if they did-although if they did if she knows the name of the person she could probably seek out some ACC compo if anything adverse happened as a result. We treat many over 70s, over 80s in our service, and the ones that warrant stenting get it, as do the ones that warrant bypass. There isn't really rationing the way opponents of socialised medicine like to think there is. There wasn't really in Ireland either. In certain cases, if someone has a lot of comorbidities, the cardiothoracic surgeons and anaesthetists will deem them a high risk surgical patient and be extremely reluctant to perform surgery. If the patient, or their family really still want it after this, it can still be done, after they consent and understand how high risk it is. I can't comment on what it was like 15 years ago, as I wasn't here (15 years ago I was barely in high school!) but certainly now age does not appear to be a barrier to any treatment in NZ. Kiwis tend to live a lot longer than the patients I was used to seeing in Ireland! I've treated people who were over 100-and they were independent and still going strong. I think all the sports and outdoorsy stuff must be a factor. Age can be a limiting factor in Ireland. Perceptions of what age a person is deemed elderly at are different there. In saying that, no treatment is ever refused to someone who wants it or needs it. It's more that the people themselves often think-"ah sure I'm too old to be going through all that" and they refuse CABGs etc. Hence the amount of elderly people who get them is lower.

There has always been the option in Ireland of having private insurance and choosing to use it when the public system posed too long a wait. The socialised system traditionally was for Irish citizens ONLY, and foreign nationals had to pay like everybody else. GPs are semi privatised there, over 70s and under 5s they have to treat free, but everyone else has to pay and it is fairly expensive, unless they have been issued a government issue medical card that is only given to low income families and welfare people, in which case they go free. It used to be in Ireland that taxes increased with the amount you made, but your pension increased, as did your PRSI-pay related social insurance. For example-after 5 years continuous working in the public system in Ireland, your PRSI pays for dental treatment and eye appointments. Consultants who have been earning 250K a year and paying a lot of tax end up with a 70K a year pension for life. The first-I forget how much of your annual salary is tax free, over 20something K is about 19% tax, then anything over about 60K is about 38% tax. There are tax breaks for certain expenses and mortgage relief etc, and if you have a good accountant you can still reduce your tax bill pretty well.

I think the Irish way is a pretty good mix between the USA and total socialised medicine, to be honest. There is social support and socialist healthcare available, but still the opportunity to make a lot of money without being taxed to the hilt and the opportunity to use that money to pay for private insurance if you want to.

I do have one more question-if this EMTALA passed this law but there was no definition of what an emergency condition was, can ED depts throw out people who aren't on the brink of death if they find out they can't pay? Do they get to decide what they think is an emergency condition? I had an issue with an insurance company when we were abroad in Australia-my partner had a problem that needed urgent investigation to outrule a serious condition. He was not going to die from it right away. The insurance company told me they only covered emergency treatment abroad. Well we were 12,000miles from home. They didn't realise they were speaking to a doctor, and I put it to them in such a way that they would have left themselves um, medicolegally disadvantaged if they refused. Basically, if left untreated, it could develop into a potential emergency. He was in the private hospital the next day and had everything sorted. Does this sort of reasoning apply in American ED depts?

Teresa-do expats automatically know every detail about every system in the country they were born in? My family moved when I was four, so I didn't really think about HMOs and insurance and stuff much then. More, you know, "where's my Lego" type thoughts. I have never lived in the US, and will never. I was asking for information out of interest. "There is no universal health insurance in America. The only people who suffer here are those who choose not to seek treatment for one reason or another. "So what happens if you get cancer? Last I heard, you couldn't get that treated in the Emergency dept. So are those without insurance able to access some medical care in the event of developing leukaemia or breast cancer or something, or do they have to go dig a 6 foot hole? If they "choose to seek treatment", is it available? I'm not being sarcastic, I just actually don't know. Remember, those of us outside the US have only really ever seen "Sicko" by way of knowing what the system is like. My parents think it's evil and don't talk too much about the States, except to nag me to make sure my insurance will cover when I go on hols there. So I have no real way of knowing what it's like except what I read on blogs etc.

gina, i'll answer more later, but i must say this. michael moore is an evil propagandist. the hippie-cruchy-academic crowd see his movies, otherwise he makes his money overseas selling his 'evil america' garbage. sicko is to our medical system as michael moore is to thin.

Teresa-do expats automatically know every detail about every system in the country they were born in?

It was YOU who proffered your expat status as part of your credentials:

As an expat American doctor who has trained and worked only in socialised healthcare systems (first Ireland and now New Zealand),

Why bring it up? It appears to be totally irrelevant to your arguments.

So what happens if you get cancer?

If you wish, you go to a doctor and get treatment. However, most Americans don't actually know they have cancer until they see a doctor who diagnoses it.

Last I heard, you couldn't get that treated in the Emergency dept.

In America you can go to the ED for any reason whatsoever. You say you've been reading American ED physicians' blogs--then you should already know that they do a LOT of primary care.

You might not be treated for cancer in the ED, but you probably would get a referral. It would be up to you and the doctor who treats you to determine if and how you pay for it.

So are those without insurance able to access some medical care in the event of developing leukaemia or breast cancer or something, or do they have to go dig a 6 foot hole? If they "choose to seek treatment", is it available?

Of course, it's available. I don't know of anyone who has actually been refused treatment because they couldn't pay. There are probably people who don't seek treatment for a variety of reasons, the cost of it being one of them.

I'm not being sarcastic, I just actually don't know.

I believe you, but you should read more closely, because we've been telling you these things.

Remember, those of us outside the US have only really ever seen "Sicko" by way of knowing what the system is like. My parents think it's evil and don't talk too much about the States

Is is possible that your parents and Michael Moore have biased you with false or slanted information? Possibly you have been misled.

well 'dr gina', it seems you don't know your system too well... it seems that new zealand does indeed have a rationed care system. here's the link and here's the point...

"These are, of course, highly contentious issues. New Zealand faced them bravely by instituting a point count system to measure need, and setting thresholds for entitlement to service in the public system."

and this...

"Rather than taking a New Zealand-type approach and draw a firm line that separates the eligible from the ineligible, in Canada we fudge the question in two ways. Either we make people wait (push them down the priority list), or we perpetually expand the eligibility pool by adding resources, in effect buying our way out of uncomfortable choices."

I'm an office manager in a private geriatric and family medical practice (80% Medicare & Medicaid). A HSA for my family of 3 through the practice costs $1,000/mo. That's with a $10,000 deductible! When I became very ill and needed Levaquin it costs me $200 out of pocket for 7 pills. My son had to visit the ER in 2007 and I am still paying it off every month. I've been informed by the insurance agent that the premiums will be going up. Yes, we shop plans. Health insurance is ridiculously expensive in Colorado. The insurance disincentivizes us from getting medical help when we need it because the out of pocket expenses are so high. We live from paycheck to paycheck.

You may be against universal health care, but do you think THIS is the answer?!

the answer is to make everyone pay something for their care. this will make them more responsible about their health and will drop your premiums immediately. right now you are paying for 10 other people who use the ER for 'free' under EMTALA.

Okay, 911 doc, I hear ya. But how do you make "everyone pay something for their care" when half of them don't even have the $2 co-pay for their Medicaid office visit in our clinic? What should we do with the "10 others paying using the ER for free under EMTALA?" Seriously. (We have a whole patient population that does this...big surprise). If they're poor or disabled, they're poor & disabled, right? How do they pay?Should we deny them care? I'm struggling with this everyday...big time.

i think you have a misapprehension of the state of 'the poor' in this country. part of my answer will be from personal experience in the ER and part will be boring stats from the IRS.

first of all, there are myriad programs for the poor and downtrodden which provides them access to health care. many folks i see who are 'uninsured' in the ER are eligible for these programs but haven't bothered to apply so we do it for them. they are calledmedicaire/medicaid/SSI. now you can't live like bill gates on this but you can live.

it is a running joke in the ER that, typically with people we take care of for free, that we must ask them to turn off their cell phones when we walk in the room. this is true to the point that i bougth a cell phone jammer because it wastes my time and the nurses time to wait for patients to finish their cell phone coversations.

also, on the way to work today i saw a sign for a number to call for 'government supported cell phone access'.

my point is this. people have learned that they need not budget for health care and EMTALA has caused the price of care and insurance to skyrocket to the point that many people can't afford insurance. no matter, it's free.

now when the government takes something valuable, like good health care, and mandates that it be provided regardless of a patients ability to pay it sounds really neato. the long term consequence, however, is that, just like in hawaii, responsible people get pissed and drop their insurance because they are paying for all the free stuff for others and why should they?

the answer from the left for this, much as in the subprime mortgage crisis which they caused, is to get the government MORE involved.

the least efficient way to distribute valuable resources is through any centralized system. this used to be taught in school, the whole 'supply and demand' thing, but today, people believe that when oil prices rise that it's the evil oil companies fault.

never mind that the supply has been artificially limited due to drilling bans and that the government taxes each gallon pumped to the tune of a dollar or so.

in health care the supply of quality health care has been artificially limited because physicians are in a triple bind...

one, they can not refuse to see any patient in an 'emergency' based on their ability to pay. folks will tell you this happened all the time prior to EMTALA but what really happened prior to EMTALA is that the critically ill were transported from private hospitals to charity or city hospitals where they still received excellent care though they may have had to share a room with four others. also, in these hospitals, residents and interns learned how to be doctors. that was the trade-off.

business being much more efficient at containing costs and turning a profit than any government entity, has done the following... they have closed ERs. ERs now lose money.

this is the second bind. ER docs are leaving rural communities, much as i have and 'cat will do shortly, and the reason is that subspecialists have quit practicing in smaller hospitals. they are all on staff at large academic centers, massive city hospitals, or they surrender their hospital priveleges and open a surgical center where EMTALA doesn't apply.

this leaves ER docs hanging in the breeze because while we are great at taking care of the emergently ill patients for the first hour or two we CAN NOT do the bypass or the stent or take out the appendix.

this delays care while we beg the big hospitals in the big cities to take these patients which they are required by EMTALA to accept.

problem, the big hospitals are now full all the time. with lawyers breathing down our necks about malpractice a lot of us are simply opting out of doing emergency care and opening our own clinics again, outside of EMTALA.

the third bind comes in the large city or univerity hospitals. with the collapse of rural care, they are truly full all the time. if they are full they can't take you no matter how sick you are.

so, an artificiall and unfunded mandate to provide care for all (including illegal aliens) regardless of their ability to pay has had the obvious consequence of increasing demand for this valuable service and doctors have, predictably, otped out.

we may be a lot of things but most of us are husbands, mothers, single parents, and most of us like to have a life outside of medicine. we tend to have this overly developed sense of responsibility to our patients to be sure, but to our families too.

if medicine was still based even loosely on a market model then as the demand for emergency care increased the supply would too and the prices, with fair competition, would be more reasonable.

my father in law, a retired government employee with full insurance, paid $400 for an EKG and $40 for an aspirin tablet during his heart procedure. yes it's ridiculous but it's how hospitals are making up for all the care they have been mandated to give away for nothing.

you might find it interesting to know that dentists, chiropractors, veterinarians and other 'health care providers' are NOT mandated to provide care to anyone who can't pay. consequently there are no shortages of these types of care.

to summarize, if there truly are people that can not afford to pay even two dollars for an ER visit then they qualify for existing government programs. the problem is, most who claim they have no money or jobs are lying. witness the fact that they mostly drive themselves to the ER, talk on their cell phones, and are obese. poor people are thin, not fat, but in america poor people are fat.

you may choose not to believe me about this and that's fine, but all you need do is volunteer in your local ER and see how many of the 70% we see with 'no money and no insurance' look thin or walked to the ER. people may be stupid as far as book learning goes but they are smart not to pay for health care when they can get it for free.

if you are even mildly interested in what i'm saying read thomas sowell's BASIC ECONOMICS. if you hang out with overeducated slackers they will tell you that thomas sowell is the worst kind of vermin, a black man (PhD in economics) who is conservative and a member of the hoover institution at Stanford University. if you can get past this little bit of racism then the book is an eye opener.

what follows are some stats from the IRS that you may not believe but they are from the IRS.

...

This is the data for calendar year 2003 just released in October 2005 by the Internal Revenue Service. The share of total income taxes paid by the top 1% of wage earners rose to 34.27% from 33.71% in 2002. Their income share (not just wages) rose from 16.12% to 16.77%. However, their average tax rate actually dropped from 27.25% down to 24.31%

*Data covers calendar year 2003, not fiscal year 2003 - and includes all income, not just wages, excluding Social Security

Think of it this way: less than 3-1/2 dollars out of every $100 paid in income taxes in the United States is paid by someone in the bottom 50% of wage earners. Are the top half millionaires? No, more like "thousandaires." The top 50% were those individuals or couples filing jointly who earned $29,019 and up in 2003. (The top 1% earned $295,495-plus.) Americans who want to are continuing to improve their lives, and those who don't want to, aren't. Here are the wage earners in each category and the percentages they pay: The top 1% pay over a third, 34.27% of all income taxes. (Up from 2003: 33.71%) The top 5% pay 54.36% of all income taxes (Up from 2002: 53.80%). The top 10% pay 65.84% (Up from 2002: 65.73%). The top 25% pay 83.88% (Down from 2002: 83.90%). The top 50% pay 96.54% (Up from 2002: 96.50%). The bottom 50%? They pay a paltry 3.46% of all income taxes (Down from 2002: 3.50%). The top 1% is paying nearly ten times the federal income taxes than the bottom 50%! And who earns what? The top 1% earns 16.77% of all income (2002: 16.12%). The top 5% earns 31.18% of all the income (2002: 30.55%). The top 10% earns 42.36% of all the income (2002: 41.77%); the top 25% earns 64.86% of all the income (2002: 64.37%) , and the top 50% earns 86.01% (2002: 85.77%) of all the income.

The Rich Earned Their Dough, They Didn't Inherit It (Except Ted Kennedy)

October 10, 2003

The bottom 50% is paying a tiny bit of the taxes, so you can't give them much of a tax cut by definition. Yet these are the people to whom the Democrats claim to want to give tax cuts. Remember this the next time you hear the "tax cuts for the rich" business. Understand that the so-called rich are about the only ones paying taxes anymore.

I had a conversation with a woman who identified herself as Misty on Wednesday. She claimed to be an accountant, yet she seemed unaware of the Alternative Minimum Tax, which now ensures that everyone pays some taxes. AP reports that the AMT, "designed in 1969 to ensure 155 wealthy people paid some tax," will hit "about 2.6 million of us this year and 36 million by 2010." That's because the tax isn't indexed for inflation! If your salary today would've made you mega-rich in '69, that's how you're taxed.

Misty tried the old line that all wealth is inherited. Not true. John Weicher, as a senior fellow at the Hudson Institute and a visiting scholar at the Federal Reserve Bank, wrote in his February 13, 1997 Washington Post Op-Ed, "Most of the rich have earned their wealth... Looking at the Fortune 400, quite a few even of the very richest people came from a standing start, while others inherited a small business and turned it into a giant corporation." What's happening here is not that "the rich are getting richer and the poor are getting poorer." The numbers prove it.

Check Out the UPDATED IRS Table of Numbers from CY 2003...

(The IRS: Individual Income Tax Returns Each Tax Year 1985 - 2003) {Requires EXCEL to View}

Hi again 911 Doc,Thank you for spending so much time and energy on your response. Wow! I read it and plan to re-read it. I also plan to discuss it at the dinner table the next time the extended family gets together. The crowd does include a couple of docs and one of my sons who is a clinical PharmD at a major hospital here in Colorado. He deals with the EMTALA crowd daily. Today the two of us had lunch and I told him about your blog which he can't wait to read, so here comes another fan.

So, thank you again, lots to read..lots to think about. And...starting tomorrow in our clinic, I'm not sending patients a bill for their $2 co-pay which they have the nerve to request. No co-pay, no doctor visit.

The points system in NZ only applies to elective surgery. Medically necessary surgery required to save life, limb, prevent avoidable pain and distress and/or disability is not rationed and is not subject to this. So CABGs for people who warrant them-according to evidence based medicine-NOT patient desires-are not rationed. Oncology care is not rationed. Elective hip replacements on ambulatory patients who are gardening a little slower-these types of ops are subject to points. The docs fudge these all the time though. I prefer a system that rations elective non urgent care where there is no danger in waiting if that system takes care of everyone equally and leaves no-one without treatment or bankrupt as a result of accessing medical care.Our system is working and yours is failing, is this not obvious to you? Americans are dying for want of health insurance. The system has movies made about it, whether you agree with them or not. Most of the rest of the world cannot believe that healthcare is accessed because of ability to pay. I agree private health insurance and private hospitals should be available for people who do decide they want their elective surgery NOW and are insured or paying. I just think that for the rest, decent quality healthcare should be provided by the State.

also, even if you are correct why should i be comfoted by the fact that 'physicians fudge these numbers all the time'.

this is wrong on so many levels. first, physicians are forced to 'fudge' to get things for thier patients that they would have immediately and without question here. second, physicians are lying. third, your system has no reserve. in other words, and God forbid, suppose some whacko pops a vial of smallpox in NZ or anthrax or ebola. who will get treatment?

alternatively, assume the world economy tanks, which it is much more likely to do if the engine of capitalism and growth for the world, the US, goes socialist, then the number of times you will have to 'fudge' will go up, and then the requirements for the point system will be adjusted, and you will have a more severe form of rationing of care than you do now.

but it seems as if NZ has come to its senses. a quick look at wikipedia tells me that one CAN indeed purchase private health insurance in NZ and that it is a destination for medical tourism for PAYING PATIENTS.

"New Zealand:New Zealand is a relatively new player to the medical travel market, focusing on non-acute surgical procedures and fertility treatment. Like other Commonwealth countries, New Zealand's medical system is based on the British health system. Most of its specialist physicians have received training in New Zealand and the US or the UK, and all use English as their first language. The costs of private healthcare are significantly cheaper than the US or the UK, with packages (airfare, accommodation, medical service etc) for procedures like hip replacement, or coronary artery bypass costing in total approximately 40% of the procedure cost alone in the US. Many private hospitals in New Zealand are accredited by the national accreditation agency Quality Health New Zealand (QHNZ). QHNZ, like JCI, is a member of the International Society for Quality in healthcare or ISQua."

So it seems that what you have is a two tiered system which I am in favor of. A baseline coverage for all, supplemental for those who chose. What I oppose is a system, like Canada's, where you are forbidden by law to go outside the government system. An example of this can be found here...

http://docsontheweb.blogspot.com/search?q=blame+canada

And don't forget what I said about our abyssmal law called EMTALA, anyone, citizen or not, can show up at the ER and get care anytime anywhere in the US. if they need a cabg they get it within 48 hours. stent? within an hour. what is amazing is that we aren't already bankrupt as we seem to not care that we have 5 million illegal immigrants who own homes that are now foreclosed and millions more, nothing against them personally, but they are here ILLEGALLY. and what is NZ policy on illegal immigration??

from what i found, again based on your happy location with thousands of miles of ocean on all your borders, it seems that the problem right now is almost nill...

http://www.victoria.ac.nz/css/docs/Working_Papers/WP15.pdf

The Context and Risk of Organised Illegal Immigrationto New Zealand:An Exploration in Policy Relevant ResearchWorking Paper 15/00Abstract“People smuggling,” or organized illegal immigration, is one of the new breed of transnational issues confronting states all over the developed world. Australia and New Zealand, while not experiencing the problem to the same degree as North America and Europe, nevertheless have not been immune to attempts to circumvent their normal immigration regimes. During the last several years Australia has experienced numerous attempts to land Chinese illegal immigrants by boat. During the last year, however, these attempts have taken a new direction and the boats have been ferrying Middle East and Southwest Asian nationals from Indonesia to Australia’s northern coast. In New Zealand there has also been a relative upsurge, though much smaller in absolute terms, in refugee claimants at New Zealand airports from these same geographic regions.While there is always a possibility of an illegal immigrant vessel arriving in New Zealand, the risk appears small. Most of the boats which have plagued Australia are too small and in too poor condition to make the trip and there is little of the right kind of employment to attract those paying for passage on ocean-going ships. The risk, as seen just recently, is from refugee claimants arriving by air with some form of assistance. For policymakers the problem is clearly difficult although not intractable. Appropriate actions which need to be taken include harmonizing New Zealand’s laws with those of Australia, deploying more immigration officers overseas, and better training for primary processing officers at the point of entry into New Zealand.

but whoa! looks like about 33 got in recently and only 7 of the original 40 were caught and deported!

NZ immigration loses illegal immigrant 'pilgrims'

Updated October 3, 2008 17:20:04

New Zealand immigration has admitted it's lost track of 33 illegal immigrants from India who arrived in July, claiming to be Catholic pilgrims on their way to World Youth Day in Australia.

The AFP newsagency says of the original group of 40, seven have been found and deported, but the rest remain missing.

Members of the group claimed they had paid the equivalent of 11 thousand US dollars to an agent in India who organised their travel and told them they could stay in New Zealand permanently.

And our neighbor to the south? What is their policy if I were to sneak across the Rio Grande? Here it is...

Mexico has a radical idea for a rational immigration policy that most Americans would love. However, Mexican officials haven’t been sharing that idea with us as they press for our Congress to adopt the McCain-Kennedy immigration reform bill.

That's too bad, because Mexico, which annually deports more illegal aliens than the United States does, has much to teach us about how it handles the immigration issue. Under Mexican law, it is a felony to be an illegal alien in Mexico.

At a time when the Supreme Court and many politicians seek to bring American law in line with foreign legal norms, it’s noteworthy that nobody has argued that the U.S. look at how Mexico deals with immigration and what it might teach us about how best to solve our illegal immigration problem. Mexico has a single, streamlined law that ensures that foreign visitors and immigrants are:

• in the country legally; • have the means to sustain themselves economically; • not destined to be burdens on society; • of economic and social benefit to society; • of good character and have no criminal records; and • contributors to the general well-being of the nation. The law also ensures that:• immigration authorities have a record of each foreign visitor; • foreign visitors do not violate their visa status; • foreign visitors are banned from interfering in the country’s internal politics; • foreign visitors who enter under false pretenses are imprisoned or deported; • foreign visitors violating the terms of their entry are imprisoned or deported; • those who aid in illegal immigration will be sent to prison.

Who could disagree with such a law? It makes perfect sense. The Mexican constitution strictly defines the rights of citizens -- and the denial of many fundamental rights to non-citizens, illegal and illegal. Under the constitution, the Ley General de Población, or General Law on Population, spells out specifically the country's immigration policy.

It is an interesting law -- and one that should cause us all to ask, Why is our great southern neighbor pushing us to water down our own immigration laws and policies, when its own immigration restrictions are the toughest on the continent? If a felony is acrime punishable by more than one year in prison, then Mexican law makes it a felony to be an illegal alien in Mexico.

If the United States adopted such statutes, Mexico no doubt would denounce it as a manifestation of American racism and bigotry.

We looked at the immigration provisions of the Mexican constitution. [1] Now let's look at Mexico's main immigration law.

Mexico welcomes only foreigners who will be useful to Mexican society:• Foreigners are admitted into Mexico "according to their possibilities of contributing to national progress." (Article 32) • Immigration officials must "ensure" that "immigrants will be useful elements for the country and that they have the necessary funds for their sustenance" and for their dependents. (Article 34) • Foreigners may be barred from the country if their presence upsets "the equilibrium of the national demographics," when foreigners are deemed detrimental to "economic or national interests," when they do not behave like good citizens in their own country, when they have broken Mexican laws, and when "they are not found to be physically or mentally healthy." (Article 37) • The Secretary of Governance may "suspend or prohibit the admission of foreigners when he determines it to be in the national interest." (Article 38)Mexican authorities must keep track of every single person in the country:• Federal, local and municipal police must cooperate with federal immigration authorities upon request, i.e., to assist in the arrests of illegal immigrants. (Article 73) • A National Population Registry keeps track of "every single individual who comprises the population of the country," and verifies each individual's identity. (Articles 85 and 86)• A national Catalog of Foreigners tracks foreign tourists and immigrants (Article 87), and assigns each individual with a unique tracking number (Article 91).Foreigners with fake papers, or who enter the country under false pretenses, may be imprisoned:• Foreigners with fake immigration papers may be fined or imprisoned. (Article 116) • Foreigners who sign government documents "with a signature that is false or different from that which he normally uses" are subject to fine and imprisonment. (Article 116) Foreigners who fail to obey the rules will be fined, deported, and/or imprisoned as felons:• Foreigners who fail to obey a deportation order are to be punished. (Article 117) • Foreigners who are deported from Mexico and attempt to re-enter the country without authorization can be imprisoned for up to 10 years. (Article 118) • Foreigners who violate the terms of their visa may be sentenced to up to six years in prison (Articles 119, 120 and 121). Foreigners who misrepresent the terms of their visa while in Mexico -- such as working with out a permit -- can also be imprisoned.Under Mexican law, illegal immigration is a felony. The General Law on Population says,• "A penalty of up to two years in prison and a fine of three hundred to five thousand pesos will be imposed on the foreigner who enters the country illegally." (Article 123) • Foreigners with legal immigration problems may be deported from Mexico instead of being imprisoned. (Article 125) • Foreigners who "attempt against national sovereignty or security" will be deported. (Article 126) Mexicans who help illegal aliens enter the country are themselves considered criminals under the law:• A Mexican who marries a foreigner with the sole objective of helping the foreigner live in the country is subject to up to five years in prison. (Article 127) • Shipping and airline companies that bring undocumented foreigners into Mexico will be fined. (Article 132) All of the above runs contrary to what Mexican leaders are demanding of the United States. The stark contrast between Mexico's immigration practices versus its Americanimmigration preachings is telling. It gives a clear picture of the Mexican government's agenda: to have a one-way immigration relationship with the United States.

Let's call Mexico's bluff on its unwarranted interference in U.S. immigration policy. Let's propose, just to make a point, that the North American Free Trade Agreement (NAFTA) member nations standardize their immigration laws by using Mexico's own law as a model.J. Michael Waller, Ph.D., is the Walter and Leonore Annenberg Professor of International Communication at the Institute of World Politics, and is Vice President for Information Operations at the Center for Security Policy. He wrote this paper for the Center for Security Policy.An authoritative English translation of the Constitution of Mexico, published by the Organization of American States, appears on http://www.citizensforaconstitutionalrepublic.com/1917_Constitution_of_Mexico.html. Quotations in this document are from the OAS translation.

so, our medical system, originally based on fee for service, was successful enough, and remains barely so, to absorb millions from mexico and thousands from Canada and does it for free. why, in God's name, would we want to hand this jewel to the same government who gave us the National Endowment for the Arts (pays people to be artists) and the Department of Energy (which has produced, since it's inception under Jimmy Carter, LESS energy than the previous free market system)? why do we want to make everyone equally miserable? fairness?

the system our government creates will hurt the poor and downtrodden the most as they will 'que up' as you say. meanwhile, i'm buying medical insurance in NZ. see you soon if i get sick.

Wow, honestly I can't believe that Dr Gina is living in the same New Zealand that I lived in for 21 years, and that my parents and siblings have lived in all their lives. NZ health care is *renowned* for its rationing in order to "keep costs down". Anyone who wants to get timely treatment (and timely treatment means *not dying* - see the article linked below) is compelled to buy private insurance, having already paid their taxes to supposedly prop up the "public health care" system.

Eight people who died in 2006 and 2007 waiting for heart surgery at Wellington Hospital had avoidable delays in their care and treatment, the Health Ministry says....The Government had previously said that patients who met a treatment threshold of 50 points and had "certainty of treatment" would get their surgery within six months....A separate report issued recently said New Zealand suffered a relatively high level of heart disease, but provision of surgery was lower than in comparable countries.

And while waiting times for publicly funded cardiac surgery had reduced to clinically acceptable levels in many other countries, this had not happened in New Zealand.

The number of cardiac surgical operations declined between 2002-03 and 2006-07. The level of service patients got in Australia was 85 per cent higher than in New Zealand. Canada was 75 per cent higher and the United Kingdom was 37 per cent higher.

In August, Capital and Coast announced it planned to cut its waiting lists by sending up to 50 cardiac patients to Australia for surgery, starting with 10 patients over the first three months."

**************

Dr Gina, this news story made headlines in all the national NZ press just a couple of days before this thread started, so you could hardly be unaware of it working as a "cardiologist" in a New Zealand hospital.

I suggest you get out and see a bit more of the mess that is New Zealand's health care system before trying to pass comment on either the NZ or the US system.

For those of you who think "8 deaths isn't that many", remember that New Zealand has a small population. Later news stories revealed that during that same period there had been just 16 deaths of patients on the "waiting list" for cardiac surgery. The above-mentioned 8 were clearly identifiable as being avoidable if the patients had received surgery. A further three died of complications from the disease rather than delays. That's a horrific percentage - 50% (or more if you include the complications) of deaths being due to waiting times for critical heart surgery.

So why the waiting lists and rationed care based on the decisions of government bureaucrats? For one, it seems that many New Zealand doctors themselves are unhappy with their current jobs and voting with their feet. For a taste of what will happen in the US if socialized medicine gets introduced here, read on...

"The Pan-Professional Medical Forum, representing specialist colleges, doctor unions, medical students and the Medical Association, said yesterday after a conference in Wellington that the medical workforce was in a crisis because of the country's inability to train and retain enough doctors.

Shortages exist in virtually all specialties, but have been particularly highlighted in general practice, anaesthesia, psychiatry, pathology, ophthalmology and oncology. Even the ranks of junior doctors now have major gaps....Last year the Waitemata District Health Board restricted access to some of its gynaecology and emergency services because of doctor shortages.

The junior doctors' union said this week that the region was about 20 per cent short of house officers. The senior doctors' union says more than one specialist a week is leaving New Zealand for Australia, lured by the prospect of doubling their pay package.

Medical Association chairman Dr Peter Foley said pay was a big factor in New Zealand's loss of doctors, but the work environment was paramount.

"We can cope with the gap if we have a good environment. We now have a widening gap and no improvement in the environment.

"Why would you want to work in a New Zealand public hospital where doctors feel under-valued, we are over-managed, and there's variable clinical focus of that management.

"We have 10 or 11 district health boards understandably mostly obsessed with how to control their deficit rather than how to provide better services. If we had appropriately funded DHBs they could be focussing solely on patient quality, patient care. They could do that with more involvement of clinicians."

**************

As for myself, having seen the travails of

a) my grandmother who was one of the first female doctors in New Zealand, b) my older sister who is an anaethetist at the largest hospital in New Zealandc) my cousin who is an emergency physician who left New Zealand for Australia 3 years ago d) the results of medical treatments gone awry for my father and mother (my mother eventually dying in hospital as a result of a botched medical procedure)

I plan to put a clause in my advance healthcare directive that I will at all costs be patriated OUT of New Zealand if I ever have a serious health issue.

What is my motivation for lying, pray tell?Oh-I'm a Communist agent. That's it.I've been straight up with you. I've told you I was a junior doctor. I've never said I was a "cardiologist", either with or without inverted commas. My experience of being a junior here has been incredibly positive. The strike, the DHBs with gaps in junior rotas-to those of us fleeing the UK and Ireland it looked to us and still does, like a lot of people whining because they don't know how good they have it.If you want to see staffing shortages-go and work in Ireland. There are more doctors on at any given time here than I have ever seen. NZ docs may be voting with their feet-but there are still bloody LOADS of them from what I can see. Yes, there could probably be more cover for holidays and that-but again-coming from Ireland, there are no true staffing shortages here that I can see. NZ hospitals do insist on an excessively high level of staffing at all times as the working hours reform made it necessary to increase the number of juniors by about 500% when it was first brought in in 1985. Any gaps in staffing do not appear to be tolerated in the way that they would be back in Ireland or the UK. A big song and dance gets made. I think that's great-because it ensures that high staffing levels are maintained-but it's hardly the picture painted above.Also-people dying waiting for cardiac surgery?? Something about this doesn't add up. If they had events and were admitted to hospital-they would have been referred for surgery, hardly sent home to wait for their CABG after a STEMI and near total 3 vessel occlusion, which would constitute malpractice. There is not enough information in that article. "Eight people who died in 2006 and 2007 waiting for heart surgery at Wellington Hospital had avoidable delays in their care and treatment, the Health Ministry says....The Government had previously said that patients who met a treatment threshold of 50 points and had "certainty of treatment" would get their surgery within six months."Exactly what were they waiting for? A stable person awaiting a valve replacement is one thing. Are we talking about unstable people post STEMIs? I hardly think so.We have a guy at the moment who has been an inpatient for 2 weeks awaiting a CABG and AVR. He's having it tomorrow. That is one of the longest waits I've seen. Maybe, again, it is that I work in a large tertiary centre. I don't know.

As far as left and right goes, the only difference is the left says, 'thank you' when they rob you of taxes. We have a health care problem in the U.S:

A Need To Revolutionize The U.S. Health Care System

The following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled desperately due to the inadequate health care they receive and access: The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low. However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care costs are now well over 2 trillion dollars of our gross domestic product. This is three times the amount nearly 20 years ago- and 8 times the amount it was about 30 years ago. Most is spent with medical institutions, as far as health expenditures are concerned. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world. We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids. Our children.Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree. About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others. Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities. Health Care must be the priority immediately by the new administration and congress. Challenges include the 700 billion dollars that have been pledged with the financial bailout that will occur, since the proposed health care plan of the next administration is projected to cost over a trillion dollars within the first year or so of the proposed plan to recalibrate health care for all of us in the U.S. Yet considering the hundreds of billions of dollars that are speculated to be saved with a reform of the country’s health care system, health policy analysts should not be greatly concerned on the steakholders who may be affected by this reform of our health care system that is desperately needed. Tom Daschle leads this Transition’s Health Policy Team. And we also have Ed Kennedy, the committee chair and a prolific legislator. So if the right people have been selected for this reforming team, the urgency and priority regarding our nation’s health care needs should be rather overt to the country’s citizens.Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well. It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget. The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers. Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if they are numbered correctly to treat and restore others. Also, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today. Perhaps the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially, and health care for all completely. It should and likely will be funded by a combination of payroll taxes and general tax revenue which is realistically possible. Because the following needs to be corrected regarding the U.S. Health Care System:Access- citizens do not have the right or ability to make use of this system as we should.Efficiency- this system strives on creating much waste and expense as it possibly can.Quality- the standard of excellence we deserve as citizens with our health care is missing in action.Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.http://www.mckinsey.com/mgi/publications/US_healthcare/index.aspDan Abshear

dear 'discover what you think',seems you have discovered what a whole lot of other people think. what do you think? one question, consider patient A, who should be primarily responsible for taking care of patient A and making sure patient A can pay their medical bills?